Infertility: Treatment, Procedure, Cost and Side Effects

There are two tubes on either side which connect the ovaries to the uterus. These are the fallopian tubes, and in the majority of the cases, this is where the fusion between the egg and the sperm happens. If there is any problem in either of the fallopian tubes, then the egg cannot travel down into the uterus and there cannot be fusion. Tubal infection or salpingitis and blocked fallopian tubes are some of the most common causes of infertility. In some cases, the sperm may travel up the fallopian tube halfway till the area of blockage and fuse with the egg. This is known as ectopic pregnancy, which is out of place.

Tubal infection is often a result of sexually transmitted diseases including trichomonas, gonococci, and chlamydia. Other general bacteria like strep and staph also produce salpingitis. In most cases, tubal ligation per se is not an issue. However, it can cause problems like blocked tubes or hydrosalpinx. In these cases, the complications arise. In some women, treating these could be the cure for their infertility itself. Blocked fallopian tubes can stop the eggs from traveling down the ovaries and fuse with the sperm. If the block is removed, then infertility is solved. Similarly, if the tubes are filled with pus as a result of the infection, then it does not produce a conducive environment for fertilization.

With IVF being used as a treatment for infertility, the tubes need to be cleared for infection or blockages. These might continue to pose problems and reduce the overall success rate of IVF. These are easy to diagnose so that the infection can be completely cleared and pus drained if required. Surgical debridement can also be done if required so that the tubes are cleared. In some cases, a part of the tube may be removed so that the issue is addressed completely. A course of antibiotics is often required to completely clear the infection. After that, once ovulation is stimulated, then the eggs can travel down so that they can be retrieved and frozen for further use.

Undetected blocked fallopian tubes of silent infection (chronic salpingitis, which does not present with any symptoms) can be one of the causes of failure to conceive with IVF. This can be quite demotivating for both the couple and the medical team. With IVF, there is no clear role for the fallopian tubes, as the eggs can be retrieved from the ovaries and placed directly in the uterus. So, in severe cases of infection, the tube(s) may be even completely removed to improve chances of fertility.

With infertility on the rise, more and more couples are turning to IVF as a definitive solution. Though there are some inherent risks with IVF, the success rates have gone up significantly over the last couple of decades. This has made it extremely popular for a couple facing infertility. IVF is no longer just a physical issue but also a hugely emotional one.

There are various factors which determine the success rate of IVF, and a thin endometrium is one of them. This is the inner lining of the uterus which should facilitate transfer and growth of the embryo throughout the course of pregnancy.

Ideally, the endometrium should be about 7 to 8 mm thick and have a 3-layered structure on ultrasound. If it is too thin, it may not be able to support the implantation of the fertilized egg. Further, even if it supports initially, as the embryo continues to grow, it may not be able to support the weight, leading to possible miscarriages.

Causes of the thin endometrium:

1. Reduced blood supply to the uterus
2. Reduced levels of estrogen
3. History of endometriosis
4. Scar tissue from prior uterine infections or surgery
5. Fibroids

While blood tests can help identify reduced estrogen levels, ultrasound can be used to measure blood flow to the uterus. The cause of thin endometrium needs to be addressed before going ahead with IVF so that the chances of success are increased.

Management:

1. Estrogen supplements can be given if there is estrogen deficiency. This is essential to promote overall uterine health, which can sustain a healthy pregnancy.
2. Surgically, uterine scraping where the top layers of the uterus are stimulated to produce a thicker lining. This is an outpatient procedure and produces excellent results in most women.
3. Increased intake of L-arginine is another way to improve uterine health. It promotes blood flow, thickens the uterine lining, and improves the success rate. About 500 mg per day for about a month is considered beneficial.
4. Uterine cleansing with for instance castor oil is another way to improve uterine lining.
5. Uterine massage where herbal oils are used to massage the pelvis has also shown great results. It helps improve circulation to the uterus and surrounding reproductive organs and improves their overall health. This should be done about 2 to 3 months before IVF and stopped after IVF (can result in dislodgement!!)
6. Acupuncture: Another well-established method to improve uterine lining and health is the use of acupuncture, as it improves circulation.
7. Eating healthy, vitamin supplements if required, getting adequate rest, moderate workout, and quitting smoking all go a long way in improving uterine health.

Intracytoplasmic Sperm Injection (ICSI) is an artificial procedure similar to IVF. This technique is mostly preferred in case of severe male infertility issues like ejaculatory failure, low sperm count and Azoospermia. ICSI is a refined version of IVF where a single sperm is strengthened and injected into female ova (egg) to initiate conception. The diagnostic and screening process is similar to IVF. ICSI is recommended when:

• The shape of the sperm is abnormal
• The previous IVF cycle fails to produce any fertilized egg. In this scenario, ICSI technique may be used for the next IVF cycle
• The sperm is not strong enough to reach the female egg through natural means
• A male who had vasectomy previously needs sperm to be extracted to fertilize the female egg

ICSI-IVF Procedure:

• Ovarian fertility drugs are given to a woman by an embryologist to produce healthy eggs for fertilization and follicles are examined by ultrasounds and blood tests until eggs get matured.
• Eggs are retrieved from the female ovary with the help of a tiny needle that is attached to the ultrasound probe.
• Fresh sperms are collected on the same day of fertilization and placed in a culture with eggs.
• Each egg is then injected with sperm and left for fertilization.
• The embryo thus formed, if found good enough, is transferred to the uterus through the catheter with ultrasound.

Advantages

• As mentioned earlier, ICSI could help in producing a genetic child even when the male has fertility issues.
• There is a greater chance of fertilization and embryo formation in ICSI compared to IVF.
• The success rates of ICSI and IVF are similar and ICSI can be away when the cause of infertility cannot be determined.

Risks involved

• The side effects in ICSI are similar to those associated with IVF.
• Multiple pregnancies, OHS (Ovarian Hyperstimulation Syndrome) due to stimulating drugs administered for IVF and embryo growth failure.
• Since ICSI requires precision while injecting sperm, there is a rare possibility of damage to the egg if not done carefully.
• The male offspring produced through ICSI may have infertility issues passed genetically.

Some couples have already used ICSI successfully and rate it highly as it is convenient and the possibility of congenital disabilities is minimal. The advantages of ICSI far outweigh the risks involved. In case you have a concern or query you can always consult an expert & get answers to your questions!

Frozen Embryo Transfer or FET is an extremely effective method to conceive a pregnancy. Recent studies have proved that there is a increased chance for pregnancy when the embryos, which get used are frozen and get placed inside the uterus at a time right after the ovaries are stimulated. Still, certain issues can arise with the transfer of frozen embryo, such as:

A Thin Lining of the Uterus
Research has shown that there are not many women who get pregnant if the lining in their uterine does not tend to thicken enough. It is not clear exactly why this problem occurs in most women and moreover there is no sure shot treatment to make the lining of the uterine thick. The experts on fertility would try out different methods like increasing the amount of estrogen or change the way how estrogen is given. There are other instances when women might be given supplemental medicines, while for some, the problem will continue to exist.

What Should Be Done In Case The Problem Persists?

• In case the problem continues for some women, then there are certain approaches which experts might look to adopt. The first one is to cancel the transfer of embryo and try once again at any later stage, that too with a different treatment method.
• The second option which they could think of is to go ahead with the transfer, wherein they might feel that a thin lining does not necessarily mean that it is impossible for a woman to get pregnant but definitely the efficiency would be reduced.
• One last option is to make use of the opportunity for undergoing additional tests which would help them to assess the ability of the uterus to allow implantation of the embryos.

Unexpected Ovulation
For enabling the embryos to get implanted into uterus, placing them very precisely and at the appropriate time is important. This is regarded as the window of implantation. The time taken, is based on the time frame since progesterone reaches the lining of the uterine.

Doctor knows the exact time to place the embryos, right from the time he or she instructs a woman to start having progesterone supplements. In case a woman was to ovulate, the production of progesterone would begin earlier than the normal time and would lead to the shift of the window of implantation. As identifying the correct time of ovulation is almost impossible, so that would lead to some sort of uncertainty into the timing.

Due to this reason, there are doctors who would use medication in order to prevent unexpected ovulation from occurring. Generally an injection called Lupron is usually used as medication.

Timing for the Embryo Transfer is Inappropriate
This is a problem related to early ovulation. There are case when the implantation window is shifted, still the timing of the transfer becomes accurate. Recent studies have shown that quite a nominal percentage of women might have a window of implantation, which could be either earlier or later than normal time. A test called the Endometrial Receptivity Array can help determine at what time is the window of implantation open. In case you have a concern or query you can always consult an expert & get answers to your questions!

Diabetes is often associated with heart diseases. In fact, many people do not know that their kidneys and eyes, too, can be affected due to the increased blood sugar levels. Fertility is often forgotten in this list. Yes, diabetes can lower the fertility rates. In men, it can cause erectile dysfunction and decrease libido. In women, the issues are different. But you should not lose hope if you are a diabetic and want to get pregnant. Controlled sugar levels and healthy body weight can help you become a mother. It should also be understood that diabetes alone cannot be the reason for you not getting pregnant. Several underlying factors such as obesity, polycystic ovary syndrome (PCOS), and irregular periods can be responsible as well.

Diabetes and hormonal disturbances: PCOS results in higher amounts of testosterone, which is the male hormones. This leads to abnormal periods, or at times, the periods are absent in women affected with this disorder. PCOS is often associated with obesity and type 2 diabetes. In women affected by diabetes, the fertility period is lowered. For instance, if a woman without diabetes can conceive up to 40 years, the diabetic woman can conceive up to 34 to 36 years only. This also means that menopause occurs early in such women. Oligomenorrhea and secondary amenorrhea are often connected to type 2 diabetes. It is also seen when these women have a control over their sugar levels, their fertility rate improves.

Type 1 diabetes and fertility: When a woman is affected by type 1 diabetes, mensuration ceases in most cases. Studies indicate that only 2 percent of the women who are affected by type 1 diabetes are able to conceive. While treatment can bring back mensuration in these women, irregular periods cannot be treated successfully. With controlled sugar levels, one can find chances of improved fertility rates. For this, even during the planning period, the woman has to control sugar levels. You can still become pregnant even when you are dependent on insulin. Your requirement dosage can differ. So, check with your primary care provider and gynecologist on the same. Your sugar levels should also be under control throughout your pregnancy.

Type 2 diabetes and fertility: In case of type 2 diabetes, which has begun to develop even in young women, there is a negative impact on the fertility rates. In the past, type 2 diabetes, also known as diabetes mellitus, was common only in the age group of 45 and above. But, lifestyle modifications and food habits have made it common even in the younger age group recently. This has resulted in the lowering of the fertile years and an early advancement of menopause. In women who have hormonal imbalance and diabetes, the combo paves the way to PCOS. Obesity is one of the reasons that trigger both diabetes and PCOS. With additional healthcare, you can become pregnant with diabetes mellitus. A healthy diet plan and exercise routine are recommended by the doctors.

If you are diabetic and planning for pregnancy, ensure that you take proper care to manage blood sugar levels. Enhanced glucose levels can only increase the risk for diabetes in the child. A healthy pregnancy is assured with controlled diabetes.